VBS Registration for kids with Special Needs and their siblings (age 3 through grade 5)
VBS Dates: Monday, July 15th through Thursday, July 18th
9:00 am to 11:00 am

Location:
Hope Presbyterian Church
5220 S. 159th Avenue
Omaha, NE 68135-3107

Registration due by July 1st
(Space is limited so register soon!)
Cost: $10 per child, $30 max per family

Payment can be made the first day of VBS.

If you have any questions, please contact Kristi Richling (402-699-0328 or klrichling@gmail.com) or Lucy Gunning (402-699-2798 or lu3putt@gmail.com).

Parent Name *
Your answer
Phone Number *
Your answer
E-mail *
Your answer
Address *
Your answer
Emergency name and contact number *
Your answer
Child's Name *
Your answer
Is this a child with special needs, a sibling or a peer model? *
Age *
Your answer
Grade Completed *
Your answer
Does you child have allergies (i.e., seasonal, food, etc.) *
If "yes" to allergies, please list. (A daily snack will be provided, so please inform us of any food allergies/restrictions.)
Your answer
Does your child have other health concerns? *
If "yes," please explain.
Your answer
Is your child potty trained? *
If "no," does he/she use diapers or pull-ups?
How does your child communicate? Please check all that apply. *
Required
Will your child be bringing his/her own AAC device? If so, please name.
Your answer
I understand that my child's picture may be taken and may be used in church publicity. Please sign below for consent. *
Your answer
I understand that I am registering my child to attend the VBS for kids with special needs and their siblings. Please sign below for confirmation. *
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service